Palate Distraction

WHAT IS PALATE DISTRACTION?

This is a surgical procedure to increase the width of the palate and the upper jaw to correct facial asymmetries as you can see in the figure below:

A device called "Palatal Distractor" is surgically installed and allows gradual increase of the width of the palate. This is made possible with a small instrument resembling a key which is provided by us.
This procedure is very often associated with orthodontic treatment.

One requirement before these procedure can take place is detailed consultation with an orthodontist. This is happily provided by our maxillofacial surgeons regarding cases.

It also includes a study of casts made from your dental impressions, a study of your dental articulation (relations between the teeth), a frontal and profile radiograph (called cephalometric x-ray), and last but not least a study of your temporomandibular joints (TMJs).

MAIN OBJECTIVES OF THE SURGERY:

• The maxillary teeth (upper jaw) naturally cover and to a certain degree extend the teeth of the mandible (lower jaw). Cross bite is the condition called when this is not the case. Palatal distraction allows  for the correction of cross bites and restores a natural occlusion (closing of the jaw). This will not only facilitate mastication (chewing) and relief pressure on the temporomandibular joints (TMJ), this also prevents; teeth from unnatural wear and tear, gingival tissue retraction.

• Correcting jaw width by restoring a normal horizontal relation of the dental arches: when the upper dental arch is lacking width (maxillary hypoplasia) in relation to the lower arch.

• An improvement of the respiratory function in the cases of sleep apnea syndrome, and a better position of the tongue.

Palates that are too narrow are often associated with mouth breathing during childhood with a lower position of the tongue. 

The restoration of a correct palate width allows the tongue to occupy its right position and promotes nasal breathing, which is significantly better for the body (the nose filters particles in the air, has a role in thermoregulation and humidifies the breathed air).

• Although this intervention has the main purpose of restoring and correcting functionality, it also brings overall improvements to add to the harmonious attributes and aesthetics of the face, such as a more radiant smile. This correction is also very much seen from a profile POV especially when this procedure is combined with another osteotomy.

TESTS PRIOR TO SURGERY:

The surgical procedure is performed under general anesthesia and will thus require one to two days of hospital stay over.

If you wish to have a private room, please inform the anesthesiologist and the surgeon as soon as possible and complete the administrative formalities specific to hospitals for private rooms. These beds require a booking in advance.

The preoperative examinations usually consist of a simple blood test, an electrocardiogram and depending on the precondition of the patient, an x-ray of the thorax. Once this is completed an appointment will be arranged for a last preoperative dialogue with our anesthesiologist who will use your test results as foundation that consultation.

THE ACTUAL SURGICAL PROCEDURE:

In addition to general anesthesia our surgeons always apply local anesthesia in all affected areas to relief patients of possible post-op discomforts when awakening is due.

Using two small screws, palatal distractor is installed on the palate using the highly precise measurements yielded by the pre-operative analysis.

An incision is then made in the mouth, above the gum and well above the upper teeth (all incisions are made intra-orally meaning they are not visible due to the fact that the visible facial skin remains untouched throughout this procedure).

Our surgeon then proceeds with a precise and rigorous corticotomy: involving horizontal and median separation of the maxilla. This allows activation of the palatal distractor and yields the millimeter gap between the central incisors we are looking for. The procedure ends with neatly applied absorbable suture meaning they will dissolve harmlessly in the body over time without any intervention.

The length of surgical procedures are always case dependent. The procedure regarding palatal distraction ranges somewhere between 40 to 75 minutes.

ACTIVATION OF THE PALATAL DISTRACTOR:

This step is of great essence for the post-op restoration and correction of the palatal width to take place. The longterm success of this particular surgery is highly dependent on these step and therefore also on you since the activation is done manually by the patients themselves, or in some cases by relatives taking on the roll as caretakers.

Please pay close attention to these steps:

The palatal distractor has, depending on which type, either got 3 different colors or 3 different numbers. This makes it possible to quantify the activation.

The manual activation of the distractor is commenced by the operating surgeon post-op, and consists of a width of 1 millimeter. Manual activation is always carefully explained to patients and, if present, their caretakers. This takes part under the supervision of the operating surgeon to make sure the activation takes place correctly in accordance to the given instructions.

As a patient you are provided with an activation key before leaving the hospital. You are then scheduled to begin the manual activation on the fifth day following your surgery ( 5 days after your surgery). You will do so by holding the key  from the end which includes the key-handle and placing the opposite end in the center of the palatal distractor. The key-handle must be placed close to the upper central incisors entering the designated location almost horizontally, the distractor is then, as the picture shows, activated by turning the key-handle DOWNWARDS (with an anti-clockwise direction).

Turning it widens the palate. You are scheduled to manually activate the distractor two times per day, every morning and evening. Appointments are made with your surgeon once to twice a week for at least the following 8 weeks to follow-up and confirm a sound and safe correction and healing process. Check-ups are then made until the distractor has reached the desired gap. Since the success of this surgery depends on regular post operational follow-ups, it is highly recommended that patient do not miss any of their scheduled appointments.

Once the gap between the central incisors is adequate (it can vary from a few millimeters to more than one centimeter depending on what has been planned), the surgeon will put a screw in the distractor to block it. This screw is called a locking screw. The distractor will be removed under local anesthesia or under sedation 3 months after putting in the locking screw.

POSTOPERATIVE RECOVERIES AND INSTRUCTIONS:

Directly after the surgery, you'll be taken to the recovery room, in which your parameters are strictly monitored (temperature, pressure, breathing, heart rate...like after any surgery).

You'll spend a few hours in the recovery room before returning to your room.

You'll have some ice (cold pack) applied on your cheeks to reduce the swelling.

You may feel swollen and that your upper lip's numb (due to the additional local anesthesia given by the surgeon just before the surgery). You'll also feel the palatal distractor with your tongue, proof that the surgery went well.

The face (cheeks) gradually swells to reach the maximum 48 hours after surgery. So, don't worry if your face is getting more swollen, it's normal.

The swelling varies from a patient to another: some swell more than others. In addition, one side may be more swollen than the other.

In some cases, a hematoma may appear. All this is of course temporary. Applying ice on the cheeks immediately after the surgery and the semi-sitting position help to limit the postoperative swelling.

A minor bleeding may occur in the operated areas but disappears quickly.

A temporary mouth opening limitation can also occur, but it is temporary. Physiotherapy sessions will be prescribed if necessary.

You will also be given all the medications you need in both the recovery and private room, intravenously.

These drugs are mainly anti-inflammatories, painkillers and antibiotics.

Postoperative instructions:

• You must absolutely not blow your nose during the 4 weeks following the procedure.
• Liquid and soft food (mixed) for 4 weeks and nothing hot during the 2 days after the surgery.
• Cautious mouthwashes diluted in water, starting from the day after the surgery and for 3 weeks after each meal.
• Ice on the cheeks (cold pack) during the 48 hours following the surgery.
• Do not smoke: smoking promotes infections, reduces wound healing and increases pain.
• Thoroughly brush your teeth and gums, starting from the next evening, with a very soft bristle manual toothbrush.
• The nursing staff will be available 24 hours a day during your hospitalization. They are perfectly aware of your case, so do not hesitate to call them as soon as necessary! It's their job!
• When leaving the hospital, the nurse will give you an appointment with the surgeon, who will see you for the follow-up every week, for at least 8 weeks, to check that everything is going well until he puts in the locking screw.
• A consultation with the orthodontist usually takes place 1 month after the surgery, after approval of your surgeon.

OPERATIVE RISKS AND COMPLICATIONS:

Any surgical procedure, even performed in the best conditions of competence and safety in accordance with the current scientific data and the regulation in force, carries risks of complication. Although very rare, the palatal distraction risks are:

Hemorrhagic complication: Very rare during the surgical procedure, it can exceptionally require a transfusion of blood or blood derivatives.

Infectious complication: Also very rare, it can occur in different ways:

Cheek abscess that sometimes requires surgical drain and possibly removing and replacing the screws that hold the distractor. (I insist on the importance of not smoking after the surgery to reduce this risk!)

Maxillary sinusitis, most often treated by antibiotic therapy. In some cases, the infection may lead to the replacement of the palatal distractor by a palatal orthodontic retention device.

Nervous complication:

A loss of sensitivity that can be partial (hypoesthesia), or total (anesthesia) of the upper lip, the teeth, and lateral nasal area may occur, but these disorders usually disappear within a few days or even, more rarely, a few weeks after the surgery. A definite sensitivity deficiency is extremely rare. No motor deficiency can occur (paralysis or facial paresis): the facial nerve isn't near the operated area.

The mobility of the face, mouth and lips is therefore never affected.

Bone or occlusal complications:

A delay of bone consolidation (pseudarthrosis) is exceptional in the maxillae (some cases are described in the scientific literature).

After the procedure, the relationship between the upper and lower teeth may be slightly disturbed, but this situation will evolve favorably with the orthodontic treatment.

Joint complications:`

The occurrence or aggravation of a pre-existing dysfunction in the jaw joint (TMJ) may occur. For example, a crack and/or pain in the TMJ, or a mouth opening limitation can rarely occur. They are also usually temporary and will be treated by your surgeon, who's familiar with this kind of conditions.

In all cases, your surgeon operates and provides immediate postoperative follow-up, but also short, medium and long-term follow-up. He is trained to operate but also to manage all the possible and rare complications of surgery.

Follow every one of his postoperative advices, and know that if you have a question or face any problem, your surgeon will help you and knows how to perfectly handle the situation.

Upon admission to the hospital, the following documents will be required:

• ID card,
• Supplemental insurance documents, if you have one,
• Signed informed consent,
• Admission documents specific to the institution.